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;IN COUNTY • PUBLIC HEALTII <br /> qqFV1 <br /> ';IN <br /> HEALTH DM <br /> 304 E_WRBFR N r vlrT: TII:IRD FLOOR a STOCKTON CA 95202 a Phone: 209/46R-3420 / Z / � /! <br /> APPLICATION I 11 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE PLOYEE HOUSING OR LABOR CAMr <br /> ❑New Camp J Conditional Permit --Z Annual Permit For Calendar Year 19'! <br /> Amended Permit D Multiple Years(Permanent Housing C simip e ar+h) Date Approved <br /> + Change of Operator F of owner Date Mulled: <br /> • C1=ge of Operator AdL!1 c-. Change of Owner Address /1 I i Z�p CQ I ermit# 001462 <br /> • Additional Employees "� l Kamp ID 4 390001,6 <br /> Mime Note any C'nrrecdont er 4- ,rnge-s In Faciftl0peralarh?nmer Informalton directly on this form <br /> Site Name: GOGNA,VFRNON 39-176 Location:•—P-95PE F.�NNING RD 13959 E. Fanning Road � <br /> Operator: GOGNA,lvrERNTON <br /> - ------------------------------------------------------------------------- ------------------- <br /> Malling Address: 13959 E PANNING RD,STOCKTON CA .5215-9730 facility Phone#: 209-931-4392 <br /> - =.,... - - <br /> -.---- -------- -" p� ------- ------- - -- <br /> I*val Ownef:----- -- G ?l,%ERNON Now Owner u Yea za-1 <br /> Owner Audress: 13959 E F-ANNING RD,STOCKTON CA 95215-9730 Owner Phone tt: 209-931-4392 � <br /> Cummunity Facilities Provided by Camp: Community A7tchen: O Yes t=;No <br /> Men: Number of Tallow Number of Showers Number of Laysdorles <br /> Women:Number of Toilets Number of Showers Number of Lstvatorles <br /> "lousing Accommodations to be Utilized this Yeai: <br /> Bull Employees pu0Jl�ras ' i1 <br /> Dormitories: Owner Owned;LYH,`RV <br /> SF Dwe®Inip Owner Owned RR Cars _ <br /> Apartments MFLLRY Spaces <br /> TOTAL Of Both COLUMNS <br /> Occupancy Dates: <br /> from_,!_/_to /_/_ Crop Total Number of Days to be used this Calendar Year <br /> prom ( to—/ / cropIetal Days Occupied by 1J more Employees <br /> ——— ——-- or NgU: Camps ocrupwa cy 2S orWre en•pioyeeslor 60 orxwre days ayaw <br /> requtrc a PWbite liarterSyxwm Pe-naek <br /> ❑ Inactive In order to more^t vour/and use status.ifcamc v4IJ not b°used thts vear bid isfntexded roruse Ir the)Wure. 0teck this Box a nd <br /> Phi s appr mWors. <br /> k ee Schedule <br /> Permanent Camp cltlnual Permit$35.00+Number of Employees _$12.00 each=$ <br /> X3 Orchard Camp Permit Fee=$95.00=S 95.00 <br /> Transfer of Ownership=$20.00=S <br /> D Permit Amendment $20.00-t Number of Additional Employees —_ (i�$12.00 each= <br /> 0 —Tate Application Fee$'70.00+Number of Employees :h)$24.00 each <br /> Fee must be submitted with Application TOTAL FEE Di-TE: 9 5_(1Cl <br /> REm rr ToTAL FEE As cALcmATED ABovE 1N nm etvcxowD self-addressed ENvELoPE. M4xe CHFORM PAYABLE TO. VHS/EHD <br /> Applicant agrees to all necessory inspections Incident to issuance of a PFRmf To OPERATE. Applicant agrees that this project(camp)shalt <br /> be operated and maintained In accordance with the applicable provisions Of the EMPLOYER HOTTING ACT, CbaptAr 1.Pan 1.Division 13 of the <br /> Heats and Safely Tolle and Chapter 1.Subebopter 3.Title 25.California Code of ftuGUYonv. <br /> Applicant Name Vernon Gogna Title Owner Y,®Pwtnmldp ❑CorporAlon <br /> (AeasePR'M'orTYPE) tiddress 959 E. Fanning Road, Stoektor: CA 95215-9730 J.hone?09/931—?664 <br /> Annllcant SlenabarP - _ Date of Application I,?/1 1/9 S <br /> j-- Yrosram Kecerd W# 2'70176 FYoclltty 1D# 001444 Account iL)# 000483 <br /> Fee Amount Amount Paid I Date of Payment Payment Type I CheckPRseeip # Received By <br /> Employee#: Accl#: I Fec 10: i PR PWS ID#. P/E, <br />